Mikhail Ejov Vladimir Sergiev Alla Baranova Rossitza Kurdova-Mintcheva Nedret Emiroglu
Elkhan Gasimov
Malaria
in the WHO European
Region
ON THE ROAD TO ELIMINATION 2000–2015
SUMMARY
Mikhail Ejov Vladimir Sergiev Alla Baranova Rossitza Kurdova-Mintcheva Nedret Emiroglu
Elkhan Gasimov
Malaria
in the WHO European
Region
ON THE ROAD TO ELIMINATION 2000–2015
SUMMARY
Abstract
This is a summary of the publication in Russian (in print). The publication is devoted to elimination of malaria in the WHO European Region, which, through the huge efforts of affected countries, WHO and the international community, became the first WHO region to interrupt transmission of indigenous malaria. The report summarizes the lessons learnt, experiences accumulated and results achieved in curbing epidemics and outbreaks after malaria resurgence, eliminating malaria and preventing the re-establishment of its transmission in malaria-affected countries and the entire Region.
The publication has been prepared by WHO staff members and international consultants of the WHO Regional Office for Europe and national malaria counterparts who have been committed to and involved in epidemic containment, malaria elimination and prevention over the past 16 years (2000–2015). The publication is intended for health managers and personnel, researchers, teachers, students and everyone who is interested in tropical diseases, medical parasitology and public health.
ISBN 978 92 89053 11 2
Address requests about publications of the WHO Regional Office for Europe to:
Publications
WHO Regional Office for Europe UN City, Marmorvej 51
DK-2100 Copenhagen Ø, Denmark
Alternatively, complete an online request form for documentation, health
information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest).
© World Health Organization 2018
All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion what so ever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either express or implied.
The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health
Contents
Contributors iv Abbreviations iv Introduction 1 The road to elimination 2 Preventing malaria reintroduction, certification of malaria elimination 5 Conclusion 9
Country profiles 10
References 39
Contributors
Principal authors
M. Ejov, V. Sergiev, A. Baranova, R. Kurdova-Mintcheva, N. Emiroglu, E. Gasimov
Co-authors
I. Abdullayev M. Aksakova S. Aliyev S. Aliyeva K. Almerekov A. Beljaev V. Davidyants M. Gordeyev I. Goryacheva P. Imnadze
M. Iosava D. Kadamov S. Karimov V. Kasumov A. Kondrashin S. Mammadov E. Morozov L. Morozova L. Paronyan D. Sayburkhonov
Abbreviations
ACD active case detection
ACTED Agence d’Aide a la Cooperation Technique et au Developpement [Agency for Technical Cooperation and Development]
ECHO European Commission’s Humanitarian Aid and Civil Protection department Global Fund The Global Fund to Fight AIDS, Tuberculosis and Malaria
IFRC International Federation of Red Cross and Red Crescent Societies IRS indoor residual spraying
MERLIN Medical Emergency Relief International MPTP mass prophylactic treatment with primaquine RBM Roll Back Malaria
G. Shamgunova A. Sharipov Z. Shapiyeva S. Topluoglu I. Tyo
N. Usenbayev Y. Zhirenkina A. Zhoroev A. Zvantsov
Introduction
This is a summary of the publication in Russian entitled “Малярия в Европейском регионе ВОЗ:
на пути к элиминации, 2000–2015” [Malaria in the WHO European Region: On the road to elimination, 2000–2015] (1). The book continues the tradition of WHO to develop publications describing the fight against the main communicable diseases. These publications not only contain and offer readers the results achieved in controlling particular diseases, but, more importantly, describe the strategies, polices and approaches used to reduce or prevent the social burden of infectious and parasitic diseases.
The first successes in controlling malaria in the WHO European Region were excellently described in the monograph by L. J. Bruce-Chwatt and J. De Zulueta (2). In this historical and epidemiological study, the authors, who spent many years working for WHO, summarized their own experience of direct participation in elaborating and implementing the first attempts to eradicate malaria in the 1960s and the contribution made by other countries and experts.
Different countries had already developed their own approaches in controlling and eliminating malaria back then. This experience was put to use after the disease returned to some countries in Europe in the form of post-eradication epidemics and outbreaks of varying intensity.
The next historic stage in fighting post-eradication malaria in Europe was described in a subsequent publication presenting the situation over the 20th century’s final three decades (3). This was a new chapter in the battle, marked by the broad spread of resistance of the malaria pathogen to anti-malarial medicines, and of the vector mosquitoes to chlorine- and organophosphate insecticides. The authors described in this context countries’ efforts to control endemic malaria foci, along with the new phenomenon of mass and practically uncontrolled import of the malaria pathogen from all malaria-
endemic parts of the world to countries where malaria transmission had been effectively interrupted.
The WHO European Region had made substantial progress in reducing incidence of malaria in endemic countries by the beginning of the 21st century. This success paved the way for a transition from malaria control programmes in endemic countries to its elimination in the Region. This transition was officially formulated in 2005 in the Tashkent Declaration: The Move from Malaria Control to Elimination in the WHO European Region: А Commitment to Action (4). The Tashkent Declaration, signed by 10 endemic countries, urged countries to eliminate malaria in the Region by 2015.
In 2006, the WHO Regional Office developed the new regional strategy entitled From Malaria Control to Elimination in the WHO European Region 2006–
2015 (5). The new strategy’s goal was to interrupt transmission of P. falciparum malaria in central Asia by 2010 and, ultimately, eliminate malaria in the European Region in general by 2015.
Over the following years, some countries achieved success, and this was confirmed by WHO experts.
WHO certified malaria elimination in Turkmenistan (2010) (6), Armenia (2011) (7), and Kyrgyzstan (2016) (8), while Uzbekistan has been completing this process too.
On 20 April, 2016, the WHO Regional Director for Europe declared that the Region had achieved interruption of indigenous malaria transmission (9).
In the foreword to the World Malaria Report 2015 (10), the WHO Director-General stated that – for the first time since WHO began keeping score – the European Region is reporting zero indigenous cases of malaria.
This is an extraordinary achievement that can only be maintained through continued political commitment and constant vigilance.
The road to elimination
The malaria elimination concept that was developed at the beginning of the 21stcentury substantially changed the approach to malaria eradication concept (11). The main difference between these concepts lay in the ultimate goal:
interrupting indigenous transmission and ensuring health services’ ability to maintain this status at global (eradication) and national (elimination) levels. Malaria eradication target came with a set time frame, but malaria elimination timeframes vary depending on local conditions. Malaria control envisages reducing mortality and morbidity to a level where the disease no longer poses a public health problem. Malaria elimination is about interrupting indigenous transmission of the disease in a particular territory, resulting in absence of indigenous cases, though imported cases of malaria might continue to be registered.
The unanimous desire to suppress post-
eradication epidemics in all WHO European region countries affected by malaria at the end of the 20th century and start of the 21st century, at all social and political levels, including international participation, led to understanding the need for prompt and radical responses to the newly emerging malaria problem. Endemic countries were supported by the WHO and international partners of the Roll Back Malaria (RBM) strategy, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), European Commission’s Humanitarian Aid and Civil Protection department (ECHO), Italian oil and gas company ENI, International Federation of Red Cross and Red Crescent Societies (IFRC), Centers for Disease Control and Prevention, Agence d’Aide a la Cooperation Technique et au Developpement [Agency for Technical Cooperation and Development, ACTED], Medical Emergency Relief International (MERLIN) and United States Agency for International Development (USAID) in their malaria control efforts. All endemic countries in the Region reviewed their national malaria control strategies and reorganized their national anti-malaria programmes in line with RBM principles. Governments in endemic countries and international organizations carried out a series of
The Tashkent Declaration:
a commitment to action
The successes attained in endemic malaria countries in the European Region were recognized and commended in October 2005 Tashkent Declaration: The Move from Malaria Control to Elimination (4). The signatory countries expressed their commitment to focusing greater efforts on eliminating malaria on their territories. This commitment was reflected too in the WHO
Regional Office’s policy of promoting and supporting the new initiative to eliminate malaria in the Region by 2015. The endemic countries, for their part, asked for WHO support to develop detailed regional and national elimination strategies and turned to RBM partners for increased financial aid to implement the approved malaria elimination goals and objectives in all endemic countries in the Region.
Attention was also drawn to the need to address the issue of malaria in border areas, both within the European Region and for European Region countries bordering countries in other WHO regions.
The adoption of Tashkent Declaration paved the way to an official agreement between WHO and the endemic countries on beginning a regional elimination campaign that would be incorporated into each country’s national policy, strategy and action plans.
The Regional Strategy “From Malaria Control to Elimination”:
a policy for action
Success in reducing incidence of cases made it possible to start setting more ambitious goals and bring countries closer to their stated aim.
The rationale for development of the new malaria strategy in 2006 aimed at moving from control to elimination is based on the following principles (5).
■ Past successful elimination of malaria in practically all of Europe was achieved through universal and adequate detection and treatment of cases, rational use of vector control, primarily through indoor residual spraying (IRS) with
■ Progress in curbing transmission achieved through the Roll Back Malaria strategy made possible achieving elimination of malaria.
■ Political commitment of the endemic countries, WHO and other stakeholders and organizations making substantial contributions to control and eliminate malaria led to improvement of epidemiological situation on malaria throughout the Region.
■ Efficacious technologies and tools available to control and eliminate malaria in the regional context made this process in the Region feasible.
The above provided sufficient grounds for considering realistic plans to achieve elimination in the WHO European Region and a universal transition to new strengthened measures in endemic countries. All 10 countries affected by malaria – Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, Tajikistan, Turkmenistan, Turkey, and Uzbekistan – signed the Tashkent Declaration of 2005. This event marks the move from malaria control to elimination.
The ultimate goal of the new regional strategy was to interrupt the transmission of malaria by 2015 and eliminate the disease within affected countries of the Region. In areas and countries where malaria had been eliminated, attention was given to maintaining the malaria-free status (5).
At the attack elimination phase, a two-pronged swift and energetic action based on vector control with focus on IRS and enhanced epidemiological surveillance including case management (strong quality assured laboratory support, free diagnosis by microscopy, and radical treatment) has been applied, with a view to interrupt indigenous
transmission as soon as possible all over the target area (in all new and/or residual foci of malaria).
In support of these operations, mass prophylactic treatment with primaquine (MPTP) has been considered under the following circumstances in areas: 1) when small foci of malaria continue to exist after indigenous transmission has been interrupted elsewhere; 2) when an outbreak is reported in the attack and consolidation elimination phase – in addition to IRS, intense surveillance and response; and 3) when residual insecticide spraying does not fully interrupt transmission in the attack elimination phase. In the consolidation elimination phase the epidemiological forces took authority to finish the battle against malaria. In the attack and consolidation elimination phase passive and active case detection (house-hold visits and screening of risk groups), as well as
prompt notification, recording and reporting and epidemiological investigation of all confirmed cases and all malaria foci, their epidemiological classification were carried out as soon as possible with the aim 1) to classify the case and focus, 2) to discover evidence of any continuation of malaria indigenous transmission and to reveal its underlying causes, 3) to recommend measures to interrupt local transmission, 4) to prevent occurrence of new cases and, finally, 5) to substantiate the fact that elimination has been achieved in a given area/
country. Interventions were directed to foci and individual cases (locally acquired and imported).
Entomological surveillance was in place, too.
Leading and coordinating role of WHO in a regional malaria elimi- nation initiative
Over the last decade, the Regional Office has provided technical assistance to all affected countries for developing and reviewing national malaria control and elimination strategies, epidemic monitoring guidelines, vector control, malaria diagnosis and treatment, preparedness for epidemics, and operational research.
Regular country visits by WHO personnel and consultants have made a substantial contribu tion to assessing and monitoring countries’ situations and the recommendations made have helped to reorient national programmes where needed.
Regional meetings were organized to facilitate exchange of best practice in eliminating malaria between countries and regions (the WHO European and Eastern Mediterranean regions).
The Regional Office developed and published a number of guidelines for assisting health personnel in countries affected by malaria in the Region in planning, organizing, implementing and evaluating national elimination pro grammes as well as preparing for certification of malaria elimination.
Publications include: Practical recommendations on epidemiological surveillance of malaria in countries of the WHO European Region facing resurgence of malaria (2006) (13); Recommendations on vector control (2006, 2007, 2008) (14–16), Practical guidelines on malaria elimination in the countries of the WHO European Region (2010) (17); Operational framework on integrated vector management (2012) (18); Training module for entomologists on malaria vectors and vector control (2012) (19).
The Regional Office has provided technical assistance to Member States to draft proposals
for submitting to the Global Fund and for their subsequent implementation. Azerbaijan, Georgia, Kyrgyzstan, Tajikistan and Uzbekistan have received and made successful use of grants from the Global Fund. All of this clearly demonstrates WHO’s leading and coordinating role at the various stages of malaria control in the Region and in intensified efforts in the endemic countries in Europe to eliminate malaria.
Strengthening decision making and institutional capacities in relation to epidemic containment, malaria elimination and preven- tion
The WHO Regional Office for Europe has placed particular emphasis on training managerial and technical personnel of malaria control programmes.
Over 1999–2014, WHO held numerous training courses on the various aspects of malaria control and elimination and applied research in this field for various categories of participants – epidemiologists, parasitologists, entomologists, and laboratory professionals from the endemic countries in Europe and neighbouring countries in the WHO Eastern Mediterranean Region.
Setting up and enhancing
cross-border collaboration and co- ordination of activities on malaria elimination and prevention
In the context of malaria elimination, particular emphasis is given to situations, where there is a risk of spread of malaria between countries and regions.
To eliminate malaria in border regions, the Regional Office initiated and supported cross- border cooperation within the Region and at the interregional level, in particular with the countries of the Eastern Mediterranean. A number of meetings on this issue were held in Dushanbe, Tajikistan (2006), Antalya, Turkey (2009), Baku, Azerbaijan (2009), and Bishkek, Kyrgyzstan (2010).
Joint statements on cross-border collaboration have been signed between Azerbaijan and Georgia (2009), Turkmenistan and Afghanistan (2009), Tajikistan and Afghanistan (2010), Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan (2010).
Improving intersectoral collabo- ration on malaria elimination and prevention
During the malaria elimination and prevention of reintroduction phase, when the number of malaria cases is minimal and the disease ceases to be a major social and economic problem, maintaining inter-sectoral cooperation and ensuring sufficient financing for the final stage of malaria elimination work were critical.
Successful implementation of the elimination programme required the participation and cooperation of ministries and agencies, including finance, agriculture, utilities, education, trade, defense, and tourism, as well as the private sector.
Inter-sectoral collaboration at national level facilitated introduction of various malaria control systems. Also critical in the malaria elimination effort was including malaria control in national economic development plans. The Region’s experience demonstrates that collective effort made it possible to reduce more rapidly the risk of malaria’s spread. Reducing the social and economic burden of malaria contributed in turn to speeding up countries’ socioeconomic development.
Strengthening national and re- gional capacity for focused re- search on malaria
Applied research on P. vivax malaria is important at the stages of controlling, eliminating, and preventing resurgence of the disease in malaria-free territory.
Research conducted in the endemic countries of the Commonwealth of Independent States during this time pursued the following practical objectives for improving the epidemiological surveillance system.
1. Assess the needed quantity of public testing for malaria.
2. Identify the spatial structure of foci.
3. Study the level of glucose-6-phosphate dehydrogenase (G6PD) deficiency in the population.
4. Assess malaria susceptibility of territory and infection risks for the public.
7. Identify the taxonomy, systematics and spread of main malaria vectors in the Central Asian and Caucasus parts of the WHO European Region.
8. Study vector resistance and sensitivity to insecticides.
9. Identify the polytypical nature of P. vivax malaria vectors.
10. Perform knowledge, attitudes and practice (KAP) surveys to study attitudes to the measures implemented.
11. Use geographical information systems (GIS) in epidemiological studies.
Advocacy actions and WHO publi- cations on epidemic containment, malaria elimination and preven- tion
Over the 15-year period, the WHO European Region countries have produced a large number of publications on malaria control, elimination and prevention. The Regional Office has published monographs, guidelines, training modules, and materials/reports. These documents contain valuable knowledge on planning, implementing, monitoring and evaluating anti-malaria activities at the different stages of control, elimination and prevention. Significance of the publications should be seen as a guidance for action (20).
Preventing malaria reintroduction, certification of malaria elimination
From elimination to preventing reintroduction in malaria-free ter- ritories
In 2015, for the first time ever in the WHO European Region, there were no reported cases of indigenous malaria (9). This was the milestone marking the move to a new stage, that of preventing malaria resurgence. This means that the Region’s countries must now review their current national plans and develop programmes for preventing reintroduction of indigenous malaria transmission in their countries.
To help decision-makers and malaria programme managers carry out effectively their tasks in planning, organizing, implementing measures on prevention of malaria reintroduction and certifying malaria elimination, the WHO Regional Office for Europe developed the Regional Framework for Prevention of Malaria Reintroduction and Certification of Malaria Elimination 2014–2020 (21).
This publication addresses the issues concerning possible reintroduction of malaria in the post- elimination period, programme aims and objectives, key methods and measures for preventing malaria reintroduction, and practical, organizational and methodological aspects of the malaria elimination certification process.
Countries that have succeeded in eliminating malaria must develop strategies for preventing reintroduction of the disease. The move from elimination to remaining malaria-free can be effective only if countries have adequate systems for early detection of suspected malaria cases, objective information on absence of indigenous transmission, and reliable classification of all detected imported cases of malaria. National programmes to prevent reintroduction of malaria in malaria-free territories must continue until global eradication of all known forms of malaria in humans is achieved.
Assessing the risk of reintroduc- tion of malaria transmission
The combined effects of receptivity (ability of local vectors to support malaria transmission in a
favourable epidemiological season) and vulnerability (likelihood of import of malaria parasites into the country) determine a particular territory’s risk of resurgence of indigenous malaria transmission.
The real possibility for resurgence of transmission in malaria-free territory depends on many factors:
Environmental, climatic, social, demographic, epidemiological, entomological, and others. The level of risk will depend on the presence of the above-listed factors, the level of healthcare systems’
work, and the quality of efforts to implement
practical measures for preventing reintroduction of malaria to disease-free territory.
Assessing risk of indigenous transmission resurgence should take into account the following real factors: a) increase in the share of non-immune people following import of the disease by infected people or vectors into territory that had been freed of malaria; b) ability of local vectors to be infected by pathogenic phenotypes imported into the country; c) upsurge in mosquito activity resulting from creation of numerous anopheles-breeding water reservoirs following abundant precipitation and high river levels; d) penetration of a highly effective vector and regeneration of populations of previously eradicated vectors in potentially endemic territory.
Table 1 below can be used to assess malaria reintroduction risks.
During the prevention of reintroduction of malaria transmission phase, risks of malaria reintroduction must be identified sufficiently early for timely mobilization of the needed capacity and resources to limit the infection’s spread.
The current socio-political situation makes it essential to conduct periodic assessment of risks of indigenous malaria transmission resurgence due to increased vulnerability in central and southern Europe following the 2015 migration crisis.
Prevention of consequences of malaria importation
Territories at risk of resurgence of clinical and epidemic consequences of imported parasitic disease require ongoing training and preparedness of medical personnel to diagnose, treat, and prevent such disease. This calls for early detection of
imported cases and preventing their spread. It is crucial that travellers be informed of the precautions to take against tropical diseases and follow doctors’
recommendations, which depend on the locality, conditions, length of stay and time of year.
The main obvious preventive measures for dealing with imported malaria are early detection, reliable diagnosis, and full and radical treatment of patients and parasite carriers identified. Each case of
imported malaria must be subject to epidemiological surveillance, with clarification of the conditions and circumstances of the infection and clear classification of the social group: Migrants, refugees, tourists, foreign students, local citizens returned from an endemic country.
Epidemiological surveillance in malaria-free territories or areas
During the phase of prevention of re-introduction malaria surveillance should be maintained, as there are many challenging factors (e.g.
malaria importation in receptive areas) that need monitoring and response, because in the absence of appropriate action, an area is likely to become malarious again.
The main task of the epidemiological surveillance system in malaria-free territory is to ensure uninterrupted monitoring of the malaria situation in the country and carry out measures to prevent resurgence of indigenous transmission of the disease. A vigilance system should be integrated into the general system for epidemiological surveillance of communicable diseases. WHO recommends the following main approaches.
■ If receptivity and vulnerability are low, early case detection by a vigilant general health service
Table 1. Assessment of the risk of malaria reintroduction in malaria-free areas
Scenarios Assessment of risk factors Risk of malaria reintroduction Receptivity Vulnerability
1. + + From high to low depending on severity of risk factors
2. + – Absent, but could emerge if vulnerability increases
3. – + Absent, but could emerge if there are changes to receptivity
4. – – Absent
complemented by epidemiological investigation of every case and focus, and appropriate remedial measures, may be sufficient to prevent re-
establishment of transmission.
■ If receptivity and vulnerability increase, countries must ensure active detection of cases of infection during the malaria transmission season, which could be combined with other regular visits to residents’ homes (patronage of newborns, injections or bandaging for patients at home).
■ In localities of high vulnerability it is necessary to reduce receptivity by the use of environmentally safe methods based on ongoing entomological monitoring.
Entomological surveillance in the prevention of reintroduction phase
Entomological surveillance continues after malaria elimination, with countries keeping in place their system for monitoring, assessing, forecasting and planning measures to regulate vector populations in order to prevent resurgence of indigenous malaria transmission in malaria-free territory, and to control potential outbreaks. At the same time, interruption of indigenous malaria transmission requires modification and even exclusion of some components of entomological monitoring.
Preference should be given during this period to environmentally safe mosquito-control measures taken to improve local populations’ quality of life. Below is a list of entomological monitoring measures that should be taken at the prevention of malaria reintroduction phase:
1. perform oversight of operation, planning and construction of hydro-engineering facilities and the condition of other breeding sites of Anopheles mosquitoes;
2. monitor the abundance of preimaginal forms of Anopheles mosquitoes;
3. monitor the abundance of adult Anopheles mosquitoes;
4. identify the start and end of the malaria transmission season;
5. assess effectiveness of mosquito control measures; and
6. monitor resistance and susceptibility of mosquitoes to insecticides used.
Main approaches and activities for preventing malaria reintroduction
Continued political commitment from countries and allocation of the needed capacity and resources to maintain malaria-free status are critical conditions for preventing reintroduction of malaria. Not only local healthcare agencies but also governments have an obligation to ensure the needed personnel and resources for carrying out required preventive measures throughout the entire process of global eradication of malaria.
Tables 2 and 3 present recommended possible preventive measures to be implemented through the national programme for maintaining malaria- free status and preventing malaria reintroduction in different types of epidemic situation.
Table 2 . Recommended curative and preventive measures for different risks of malaria reintroduction
High receptivity and vulnerability Low receptivity and vulnerability
• Passive case detection
• Active case detection during the transmission season conducted every 14 days or more often in cases of renewed local malaria transmission related to imported cases
• Hospitalization of patients
• Epidemiological investigation of all cases and foci of malaria
• Timely treatment of all confirmed cases of malaria using primaquine for radical treatment of P. vivax malaria
• Passive case detection
• Hospitalization of patients
• Epidemiological investigation and epidemiological classification of all cases and foci of malaria
• Timely treatment of all confirmed cases of malaria using primaquine for radical treatment of P. vivax malaria
Certification of malaria elimina- tion
Certification of malaria elimination is the official recognition of the achievement of malaria elimination in a specific country. It is granted by WHO when it has been proved:
■ beyond reasonable doubt, that the chain of local malaria transmission by Anopheles mosquitoes has been fully interrupted throughout the country for at least three consecutive years; and
■ that the existing health system (in particular the curative and preventive services and the epidemiological service) and an adequate surveillance and response system for
preventing malaria reintroduction and possible reestablishment of local transmission is fully functional across the entire territory of a given country.
The malaria certification procedures are set out in WHO documents.
Official recognition of a country’s malaria-free status brings direct and indirect economic dividends in terms of international tourism, investment in business and mutually advantageous cooperation in various areas of international relations. For the international community, it is important to have accurate information on the real spread of malaria, which impacts a country’s socioeconomic development, and on potential infection risks.
After malaria elimination certification, countries must continue epidemiological surveillance of malaria and carry out preventive measures needed to maintain the status achieved and prevent a resurgence of indigenous malaria transmission in disease-free territory via import of malaria.
Since indigenous malaria transmission resurgence in the WHO European Region in the 1990s, three countries in the Region have been officially certified by WHO as malaria-free – Turkmenistan (2010), Armenia (2011) and Kyrgyzstan (2016).
Table 3. Recommended set of vector control measures for different risks of malaria reintroduction
High receptivity and vulnerability Low receptivity and vulnerability
• Environmental management aimed at sustained improvement of areas and rational planning of hydro- engineering and drainage projects
• Introduction of Gambusia fish into all sites where Anopheles mosquitoes breed
• Other activities against Anopheles larvae can also be applied, but only in breeding sites where the effectiveness of introduction of Gambusia is reduced by overgrown vegetation
• Indoor residual spraying should be carried out only in exceptional cases, such as when there is extensive
importation of malaria by refugees or agricultural workers, or when infected mosquitoes invade the border areas
• Vector control activities carried out as part of the general mosquito management programme
Conclusion
The WHO European Region’s vast experience in containing a regional epidemic, eliminating malaria and preventing its re-establishment should serve as a valuable example for planning and implementing of such interventions around the world to reduce the extent of this disease. At the same time, continuous importation of malaria from endemic countries and consequent recent resumption of local malaria transmission in limited areas of Georgia, Greece and Turkey that was halted by deliberate efforts of the countries, underscores the need to continue effective epidemiological surveillance of malaria in all countries where elimination has been
achieved. Bearing in mind that in 2015 the World Health Assembly approved the Global Technical Strategy for Malaria 2016–2030 with the goal of eliminating malaria in 35 countries and preventing the re-establishment of malaria to territories that have eliminated the disease, the WHO European Region’s positive lessons learnt and experience accrued over the past years on malaria elimination and prevention can be important for consideration of those countries that are on the move to
eliminate malaria and prevent its re-introduction into territories where indigenous transmission of malaria has been interrupted.
Armenia Azerbaijan Georgia Kazakhstan Kyrgyzstan
Russian Federation Tajikistan
Turkey
Turkmenistan Uzbekistan
Country profiles
Armenia
Transmission of Plasmodium vivax malaria was interrupted in Armenia in 2006, and the country was officially certified by WHO as malaria free in 2011.
Anopheles maculipennis is the main malaria vector in the country. Others include An. sacharovi and An. claviger. The appearance of An. sacharovi (the main vector in Transcaucasia) in the Ararat valley has created more favourable conditions for malaria transmission in the country.
Short history of malaria and malaria control Malaria has been highly endemic in Armenia since ancient times but was absent for 31 years, during the period 1963–1994.
From 1963, when no indigenous malaria cases were reported, control operations were sharply reduced.
After 1991, however, following the collapse of the former Soviet Union, the malaria-free status of the country was jeopardized. Several factors placed Armenia at risk for the re-emergence of malaria.
Severe financial constraints contributed to reduction of vector control activities and, because of inadequate epidemiological control, new malaria cases were not diagnosed, treated or reported properly.
Nevertheless, despite sporadic imported cases, Armenia maintained its malaria-free status until 1993 owing to a well-developed network of public health institutions.
In 1994, the first indigenous case was registered since malaria eradication, and 196 imported cases of malaria (5.1 per 100 000) were recorded among military personnel. All the cases were due to P.
vivax. The epidemiological situation and distinctive spread of malaria in Armenia was similar to that in south Asian countries.
In 1995, the number of imported cases increased to 502 among both the military and civilians, but no indigenous cases were detected that year. In 1996, 149 of 347 cases were reported as indigenous.
During 1997–1998, the number of imported and indigenous cases continued to rise, with 567 indigenous cases in 1997. In 1998, the epidemic reached its peak, with 1156 malaria cases. Although 30 of 81 districts recorded malaria cases, in 1998, 89% of the indigenous cases were detected in the Masis district of the Ararat valley, an area bordering Turkey.
The malaria situation started to improve after 1999, when 616 P. vivax malaria cases were reported in Armenia, 376 in Masis district.
Malaria situation between 2000 and the present
After 2000, due to epidemic control interventions, the number of malaria cases (imported and indigenous) continued to decline. Altogether, 79 malaria cases were registered in 2001 (32 indigenous), 52 in 2002 (13 indigenous), 29 in 2003 (8 indigenous) and 47 in 2004 (6 indigenous).
The last three indigenous cases in Armenia were reported in 2005. The dynamics of malaria morbidity in Armenia in 1994–2006 is shown in Fig. 1.
Strategies, policies and interventions After 1994, when malaria cases began to be registered in the country again, the Government paid particular attention to the problem. The
Fig. 1. Malaria cases in Armenia, 1994–2015 and phases of malaria programme
Source: National Centre for Disease Control, Armenia.
Number of cases
700 600 500 400 300 200 100 0
Imported Indigenous
195 502
198 274
614
287
82 47 23 21 41 3 0 0 1 0 1 0 4 0 1 2
Year
1991 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
national policy during this period focused on protecting the population from an epidemic.
In 1998, the Ministry of Health, with technical support from WHO and financial contributions from the governments of Italy and Norway, resumed malaria control activities. With WHO, United Nations Children Fund (UNICEF) and IFRC, a RBM programme was implemented to eliminate recently established foci of malaria and to prevent further spread of the disease.
The first malaria control programme was adopted by the Government Council in 1999, and a national coordination council for malaria was established by a decision of the President and the Prime Minister.
The coordination council consisted of various ministers, the heads of Government agencies (including health, agriculture, internal affairs, defense and water resources) and the governors of malaria-endemic districts.
Broad consensus was built among local authorities, Government departments, civil society and the media to tackle the malaria problem in the 11 regions of the country, where regional councils were formed. Particular emphasis was paid to Ararat, Armavir and Yerevan City, where malaria control activities are currently being implemented.
In 2005, Armenia and other malaria-affected countries in the WHO European Region, taking into consideration the progress achieved in control of malaria (Fig. 2), endorsed the Tashkent Declaration.
In 2006, Armenia prepared a national malaria elimination strategy, based on the results achieved so far and with the goal of eliminating P. vivax malaria by 2010.
Activities that played significant roles in the control and elimination of malaria in Armenia were:
■ inclusion of malaria control and prevention activities in the general plans of action of local health authorities;
■ staff training and re-training;
■ preparation of inpatient facilities for malaria patients (window nets, regular disinsection, stocks of antimalarial drugs);
■ provision of guidance to medical personnel;
■ laboratory testing of samples, with clinical and epidemiological observation, to ensure early detection and treatment of cases;
■ establishment of a reserve stock of antimalarial agents;
■ strengthened capacity of parasitological laboratories;
■ establishment of internal and external quality assurance for clinical and epidemiological diagnosis of malaria; and
■ social mobilization and communication for the population.
Prevention of reintroduction of malaria In 2011, the Government adopted the national programme and plan of action for the prevention of malaria reintroduction for 2011–2015. The key strategies for implementing the programme were:
■ consolidation of the system for preventing reintroduction of malaria;
■ integration of measures for preventing malaria reintroduction into the activities of the emergency programme;
■ a cross-border cooperation policy;
■ adaptation of the epidemiological surveillance system to prevention of reintroduction;
■ improved preventive and anti-epidemic measures in foci of infection;
■ preventive activities and measures for high-risk groups;
■ dissemination of information on malaria prevention and hygiene to the population; and
■ recruitment and training personnel for malaria prevention.
Fig. 2. Mapping of malaria cases, Armenia, 2000–2005
Source: National Centre for Disease Control, Armenia.
Indigenous Imported
2000 2001
2002 2003
2004 2005
Yerevan Yerevan
Yerevan Yerevan
Yerevan Yerevan
6
Outlook
The experience of reintroduction of malaria into Armenia after more than 30 years of interruption showed the importance of sustained surveillance for the prevention of resurgence. Now that the country has been certified by WHO as malaria free, continuous efforts and resources are needed to maintain a high level of vigilance and preparedness for a prompt response to prevent reintroduction of the disease.
Azerbaijan
Transmission of Plasmodium vivax malaria was interrupted in Azerbaijan in 2013, and the country is now in the prevention of malaria reintroduction phase.
The malaria vectors in Azerbaijan comprise Anopheles maculipennis (in the Caucasus), An.
sacharovi (in the Kura-Araksin and Lenkoran lowlands) and An. persiensis (in the Lenkoran lowlands bordering the Islamic Republic of Iran).
Short history of malaria and malaria control Azerbaijan has a long history of malaria. In the past, malaria was widespread, and high mortality from P. falciparum malaria was recorded in the highly endemic valleys of Kura-Araz, Samur-Devechi and Lenkoran and the Nakhchivan Autonomous Republic. In some settlements, the mortality rate was 70–100%.
During the period 1951–1960, scientific and practical organizational measures for malaria control
resulted in elimination of malaria in the country. The measures included:
■ a wide network of institutions for treatment and prevention, staffed by specialized, highly skilled personnel;
■ sufficient stocks of effective medicines (quinine, proguanil, plasmocide) and domestically produced insecticides (DDT and hexachlorocyclohexane); and
■ evidence-based malaria control methods for the different geographical areas of the country.
By 1960 malaria in Azerbaijan was practically eliminated.
The malaria situation deteriorated rapidly after 1990 as a result of almost complete cessation of malaria control interventions, hydro-engineering projects and mass displacement of nearly one million refugees and internally displaced people during armed conflicts. In 1996, 13 135 cases of malaria were reported, mainly in the Kura-Araksin and Lenkoran lowlands, areas that were highly malaria- endemic in the past. In 1997, the situation was aggravated by mudslides throughout these districts, and mosquito-breeding sites increased dramatically.
The first three-year malaria control programme was implemented in 1999, with financial support from the Italian oil company Eni, which contributed
Malaria situation between 2000 and the present
Remarkable progress was achieved in malaria control after 1997 as a result of full-scale implementation of malaria control measures, including public awareness, throughout the country.
Reductions in malaria morbidity were registered each year: in 2002 and 2003, 506 and 482 malaria cases were registered, as compared to 13 135 cases in 1996, representing reductions of 25.9 and 27.3 times. The malaria incidence per 100 000 population in 2002 and 2003 was 6.3 and 6.0, respectively. The large-scale epidemic that occurred in 1994–1997 was thus controlled within 5–6 years.
In 2005, Azerbaijan endorsed the Tashkent Declaration, committing itself to elimination of malaria in the country by 2015.
In 2008, after the 120-times reduction in the number of indigenous cases of malaria from the peak of the epidemic in 1996, the Minister of Health endorsed the national malaria elimination strategy for 2008–
2013. Implementation of the strategy was supported by the Government, WHO and the Global Fund.
In 2013, malaria transmission in Azerbaijan was considered to be interrupted, with, for the first time since 1960, zero indigenous malaria cases (Fig. 3).
Strategies, policies and interventions The goal of the malaria elimination strategy was to interrupt transmission by 2013, followed by certification of malaria elimination. In areas where malaria had been eliminated, attention was directed to maintaining the malaria-free status. Particular emphasis was placed on the growing problem of imported malaria. The interventions in the strategy included the following measures.
■ Early detection, diagnosis and treatment of malaria:
To detect malaria cases, blood slides were taken for parasitological examination from febrile patients and clinically suspected malaria cases. Passive case detection, consisting of screening for malaria cases at health facilities, was given priority over active case detection (Fig. 4); however, active case detection was conducted once a week during the transmission season in active foci and in cases of massive importation of malaria by migrants. All cases were treated free of charge.
■ Vector-control measures: indoor residual spraying, larval control and insecticide-treated
Fig. 3. Malaria cases and malaria incidence per 10 000 population, Azerbaijan, 1990–2012
Source: Republican Center of Hygiene and Epidemiology, Ministry of Health, Azerbaijan.
Fig. 4. Numbers of blood samples tested and malaria cases detected by active case detection (ACD), Azerbaijan, 2008–2012
Source: Republican Center of Hygiene and Epidemiology, Ministry of Health, Azerbaijan.
Number of casesNumber of cases Incidence per 10000 population
14 000 12 000 10 000 8 000 6 000 4 000 2 000 0
600 000
500 000
400 000
300 000
200 000
100 000
0
45 40 35 30 25 20 15 10 5 0 20
15
10
5
0
Year
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012
2008 2009 2010 2011 2012
Samples taken, total Samples taken, ACD
Number of cases
Incidence per 10 000 population
% of cases detected by ACD Year
%
■ Control and prevention of epidemics:
Experience during the explosive epidemic of malaria in Azerbaijan in 1994–1996 showed that basic preparedness and rapid response mechanisms were not in place in epidemic- prone areas, obviating early detection of malaria cases and rapid reaction. Emphasis was therefore placed on establishing mechanisms to predict, detect and rapidly respond to epidemic situations to prevent an outbreak of malaria.
■ Surveillance: Since 2009, malaria cases have been reported in an electronic integrated disease surveillance system, which integrates human and veterinary case data, demographic information, geographical information, laboratory analyses, sample tracking, epidemiological analyses, clinical information and response measures.
■ Staff development and training: Relevant specialists were trained regularly, and
guidelines and instruction materials on malaria elimination were made available.
■ Operational research for identification of Anopheles mosquitoes, their distribution in different eco-epidemiological settings and their role in malaria transmission, vector resistance to insecticides and integrated vector control in different settings.
■ Community mobilization: A number of communication campaigns were conducted, with effective information, education and communication strategies and targeted materials.
■ Cross-border collaboration: Effective operational cross-border cooperation with Georgia was established.
■ A reliable system for monitoring and evaluation was established, providing systematic analysis of the situation, and national malaria case and laboratory registers were established.
Prevention of reintroduction of malaria
In 2015, the Minister of Health endorsed the national strategy for prevention of malaria reintroduction for 2015–2020. The goal of the strategy is to maintain the malaria-free status of the country by preventing introduced cases, linked epidemiologically to imported cases, and indigenous cases secondary to introduced cases. The objectives are:
■ early detection, notification and prompt diagnosis and treatment of all malaria cases;
■ determination of the probable causes of reintroduction of malaria transmission;
■ immediate action in the event of renewed local malaria transmission; and
■ prevention of new local transmission.
Outlook
The experience of Azerbaijan once more demonstrates that high receptivity and vulnerability in the absence of adequate prevention and response mechanisms can lead to a rapid resurgence of malaria. Strong public health system infrastructure, political commitment and support, rapid resource mobilization and sustained funding are required to maintain malaria-free status.
Fig. 5. Number of indigenous cases of P. vivax malaria in Georgia, 1996-2015
Source: Centre for Disease Control and Prevention, Georgia.
Georgia
In Georgia, transmission of Plasmodium vivax malaria was interrupted in 2010. Two introduced cases were detected in 2011 and 2012; no locally acquired cases were reported in 2013. Georgia is now is in the “prevention of malaria reintroduction”
phase.
The main and secondary vectors are Anopheles maculipennis, An. superpictus, An. sacharovi, An. atroparvus, An. hyrcanus, An. claviger and An.
melanoon.
Short history of malaria and malaria control In ancient times, malaria was widespread and epidemic in Georgia. In the 1920s, approximately 30% of the population was infected (≥ 80% in the lowlands), and the mortality rate was 0.2% in 1924–1928.
Comprehensive, nationwide antimalarial measures led to a sharp decrease in morbidity by 1954 and interruption of local transmission and sustained malaria elimination by 1970.
In the middle of the 1990s, a resurgence of malaria began, with imported cases from large-scale malaria epidemics in neighbouring countries due to social and economic collapse in the region after the disintegration of the former Soviet Union, which resulted in the breakdown
of public health networks, including the malaria prevention and control infrastructure. In 1996, the first three indigenous P. vivax cases were detected in a settlement bordering Azerbaijan. In subsequent years, the number of cases due to local transmission of P. vivax gradually increased, from 14 in 1998 to 35 in 1999, 164 in 2000 and peaks of 437 cases in 2001 and 474 cases in 2002 (Fig. 5).
Malaria situation between 2000 and the present
The malaria situation deteriorated (Fig. 5), with increasing numbers of indigenous P. vivax cases and active foci. Most cases occurred in the eastern part of the country, due to importation from endemic areas of neighbouring Azerbaijan; however, there were also single cases and an outbreak (26 people affected in 2001) in the formerly endemic territories of western Georgia. Altogether, 1868 indigenous cases were reported in the period 2000–2009. With accelerated, large-scale malaria control interventions supported by both internal and external resources, the number of cases has decreased steadily since the peak in 2002. The last indigenous case was officially reported in 2009.
Importation of malaria from endemic countries continued in 2010–2015, with 4–7 cases annually.
Two cases in local citizens in 2011 and 2012 were
Number of cases
500 450 400 350 300 250 200 150 100 50 0
Year
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
classified as “introduced” by the National Malaria Programme. Prompt responses by public health facilities prevented complications and secondary cases. In 2015, a case of induced P. falciparum malaria was reported in a local nurse who was infected during venepuncture of a patient with imported P. falciparum malaria.
Strategies, policies and interventions
After the resurgence of malaria in 1996, the Ministry of Health started intensive scaling-up of control and surveillance activities. In 2000, the National Malaria Control Programme was established, according to the WHO RBM strategy, with the support of the WHO Regional Office for Europe. The programme began with only limited funds; however, financial support was provided by the Global Fund between 2004 and 2012.
Georgia has succeeded in containing outbreaks and interrupting local malaria transmission after malaria resurgence, with the following main approaches and interventions:
■ strengthened institutional capacity of the National Malaria Control Programme and general health services and enhanced capacity for decision- making on malaria;
■ better capacity for and access to timely case detection, early diagnosis and adequate treatment of malaria;
■ a national treatment protocol, which is updated regularly, in which all cases positive for vivax malaria are radically treated with a standard course of 3 days of chloroquine and 14 days of primaquine on an outpatient basis, free of charge, with a sufficient stock of drugs ensured;
■ reinforced surveillance mechanisms;
■ cost-effective, sustainable vector control;
■ improved capacity for timely response and prevention of malaria outbreaks and epidemics;
■ increased community awareness and participation in malaria prevention;
■ cross-border cooperation with neighbouring Azerbaijan; and
■ operational research on the effectiveness of interventions (e.g. vector bionomics, malaria stratification, integrated vector control) and on cultural, social and economic factors (knowledge, attitudes and perceptions and other behavioural studies).
In 2005, Georgia endorsed the Tashkent Declaration and prepared a strategy and plan of action for malaria elimination in Georgia, in line with the new WHO regional strategy and other WHO documents. In accordance with the strategy, the country strengthened malaria surveillance for timely detection of each case and to clear up the last foci (Fig. 6). A central malaria database was created to register cases and foci and compile annual reports, in accordance with WHO recommendations, in preparation for WHO certification of Georgia as a country free of malaria.
Prevention of reintroduction of malaria After successful interruption of local malaria transmission, work has been reoriented to sustain the results and prevent reintroduction.
A programme for the prevention of malaria reintroduction has been incorporated in the State surveillance programme (2012), supported financially by the Government.
2003 2004 2005 2006 2007 2008 2009
Fig. 6. Malaria foci in Georgia, 2003–2009
Source: Centre for Disease Control and Prevention, Georgia.
Foci number
80
60
40
20
0
Year
Residual non active Residual active
New active Cleared up
Outlook
Successful interruption of the resurgence of local malaria transmission in Georgia was due to strong political commitment, expertise, integrated approaches and sustainable resources. It was a long process, involving 14 years of continuous work by public and general health services, many other organizations and the entire population. Now, when the country has eliminated malaria, it should continue work to reduce receptivity and vulnerability, maintain adequate vigilance and ensure a timely response if needed.
Fig. 7. Numbers of malaria cases in Kazakhstan, 1990–2015
Kazakhstan
Malaria was eliminated in Kazakhstan in 1967;
subsequently, local Plasmodium vivax transmission was re-established in 1992 and then interrupted in 2000. The country is in now in the “prevention of malaria reintroduction” phase. In 2012, Kazakhstan was added to the WHO supplementary list of countries free of malaria.
The malaria vectors in Kazakhstan are Anopheles messeae (the most common, found throughout the county), An. superpictus, An. pulcherrimus, An.
martinius, An. hyrcanus and An. claviger.
Short history of malaria and malaria control Malaria was common in Kazakhstan in the past. As a result of a large-scale, nationwide antimalarial campaign, local malaria transmission was interrupted by 1960, and malaria elimination was confirmed in 1967.
The country maintained malaria surveillance, and only imported cases were registered in the 1970s
and 1980s. In 1992–1999, however, an increase in importation of P. vivax was seen from the countries of the former Soviet Union, where malaria epidemics had broken out, and a few introduced cases of P. vivax malaria were officially reported. Local transmission of P. vivax then resumed, and seven indigenous cases were recorded in 2000 and two in 2001 (Fig. 7).
Malaria situation between 2000 and the present
After resumption of local transmission of P. vivax, the Ministry of Health reinforced antimalarial activity, and the increased malaria control and surveillance quickly interrupted transmission and prevented further distribution of vivax malaria. Since 2002, no indigenous cases have been reported, although malaria importation continued. During the period 2000–2015 malaria, importation accounted for 135 cases.
Since 2000, after the sharp rise in the number of cases imported from malaria-endemic countries in the 1990s, there has been a steady decrease (see Fig. 7).
Number of cases
100 90 80 70 60 50 40 30 20 10 0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Indigenous
Imported
The majority of cases (114, 84.4%) were due to P. vivax and the rest to other species (P. falciparum, 14 cases;
P. malariae, 3; P. ovale, 1; and mixed infection, 3).1 Analysis of imported malaria cases in 2011–2015 showed that most were male (9 of 11), all were aged 20–40 years, more than half (6 cases) were foreign students, and malaria was imported predominantly from Pakistan (6 cases) but also from Afghanistan, Nigeria, and India. A potentially favourable factor for preventing local malaria transmission is that most cases were in towns, forming pseudofoci, and there was only one potential focus, which did not become active
Strategies, policies and interventions For rapid interruption of the renewed P. vivax transmission and to achieve malaria elimination, the country mobilized resources and scaled up epidemiological surveillance and control. In 2000, a national plan for malaria prevention for 2001–2003 was set up. With application of indoor residual spraying in the new foci and larval control (Gambusia affinis) in mosquito habitats, the level of transmission was quickly reduced. Intensified case detection (passive and active), prompt diagnosis and radical treatment led to elimination of the sources of infection. Case-based surveillance, prevention and capacity-building helped to reach the target.
These complex, integrated interventions, supported by the Ministry of Health, WHO and USAID, resulted in prevention of the spread of malaria in the
country, and the last indigenous malaria cases were reported in 2001.
Kazakhstan has committed itself to eliminating malaria, and, in 2005, signed the Tashkent Declaration.
Prevention of reintroduction of malaria After achieving interruption of local malaria transmission, the malaria programme was reoriented to prevention of malaria reintroduction.
In Kazakhstan, 4.5 million citizens in the 26 provinces live in potentially malarious areas,
although differences in eco-climatic settings, landscape, vector species distribution and occupational and migration patterns make the malariogenic potential heterogeneous. The areas at highest risk for resumption of malaria transmission are Almaty, Jambyl and South, West and East Kazakhstan and also the cities of Almaty, Astana and Karaganda.
A recent decrease in the number of imported cases and the improved malaria situation in neighbouring and other countries of the former Soviet Union have reduced vulnerability, although increasing migration throughout the world may change the situation rapidly.
The aims of the programme for prevention of malaria reintroduction in Kazakhstan are to reduce malaria potential (receptivity and vulnerability), prevent imported malaria and its consequences and establish and maintain high vigilance for cases.
The main approaches and operations are as follows:
■ timely passive and active detection of malaria cases on clinical and epidemiological indications (fever, history of travel to malaria-endemic countries) (Fig. 8);
■ quality-assured laboratory diagnosis;
■ treatment of malaria free of charge;
■ comprehensive investigation of all imported cases and new foci and management of foci, in line with national legislation ;
■ entomological monitoring at selected control points and studies on insecticide resistance;
■ vector control mainly through larval control and environmental management (Indoor residual spraying has not been used since 2010.);
■ continuous work to reduce malaria importation;
■ numerous Ministry of Health regulations and guidelines, which are updated periodically;
■ continuous training and retraining of staff to maintain malaria expertise; and
■ an agreement for cross-border cooperation for malaria elimination with Kyrgyzstan, Tajikistan and Uzbekistan, signed in 2010 in Bishkek.
Outlook
The experience of Kazakhstan shows the importance of sustainable surveillance in preventing malaria resurgence. Now, having achieved malaria elimination again, the country requires resources to maintain high levels of vigilance and preparedness to ensure a prompt response to any reintroduction of the disease.
Fig. 8. Percentages of people examined for malaria on clinical and epidemiological indications, Kazakhstan, 2010–2014
Year
2014
2013
2012
2011
2010
%
0 20 40 60 80 100 120
Individuals with a history of travel to endemic countries Local individuals with fever
Sources: Department for Monitoring of Parasitic Disease and Risk Assessment, Scientific and Practical Centre for Sanitary-Epidemiological Expertise and Monitoring, Consumer Protection Committee, Ministry of National Economy, Kazakhstan.
